- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,819.70 / $2,818.38
| Facility | | $588.84 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $1,479.11
| Professional | | $512.86 | $602.56 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $42.66 / $50.12
| Professional | | $38.02 | $42.66 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $4,073.80
| Facility | | $724.44 | $1,445.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,000.00 / $2,187.76
| Professional | | $602.56 | $1,000.00 | $2,187.76 |